Time to Redefine Obesity as Adiposity-Based Chronic Disease (ABCD)?

RESPONSE: Bariatric endocrinology evolved from the realization that fat is not just a visible nuisance.1 Adiposity is not just excess poundage that takes away from health; it is very active, metabolically. The involvement of hormone receptors and hormone production places adipose tissue at the crossroads of metabolism.1,2

Derangements in adipose tissue function, or adiposopathy, actively contribute to metabolic disease.2 Bariatric endocrinology focuses on returning adipose tissue dysfunction to normal as well as helping to decrease the burden of fat mass, and treating the complications that result from adiposopathy.1

In an effort to shift the emphasis from a medical diagnostic focus to one that recognizes the pathophysiological effects of excess weight, the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) published a position statement, arguing for--adiposity-based chronic disease (ABCD)--as a new diagnostic term.3 Adiposity, which has been defined as total body fat, its distribution and secretary function, is affected by physical and nonphysical environments including culture, beliefs, customs, society, politics and economics. The complications that result from adiposity under these influences are adiposity-based chronic diseases, such as diabetes and cardiovascular diseases.

ABCD, therefore, is advanced as new terminology to transition away from the terms overweight and obesity. The need to do so comes from over a half century of discrimination against patients with overweight and obesity. With this position statement,3 AACE and ACE set the stage for advocacy on political, economic, and social fronts, as much as to make individual patient care the standard of practice going forward.

The historical discrimination of obesity in healthcare

On July 30, 1965, President Lyndon B. Johnson signed H.R. 6675 in Independence, Missouri; this made Medicare law. The implementation of Medicare required the development of coverage rules, but since obesity was not recognized as a disease, it remained an uncovered condition, and thus began the exclusion of this metabolic condition at the federal level.

Despite the growing rates of overweight and obesity, the Healthcare Financing Administration officially ruled, in 1977, that obesity was not a disease. This move was done intentionally to prohibit reimbursement for physician office visits, dietitian counseling, physical activity interventions, pharmacotherapy, and surgery for obesity management, and since coverage was not permitted by the federal government, the states followed suit.

The third-party payer system that developed over the past 40 years was set up largely to exclude obesity care based on the premise that it would mirror federal and state coverages. In some states, there are even further restraints on medical management of obesity. For example, in Ohio, physicians who prescribe phentermine “off-label” for long-term, treatment of obesity as a chronic disease, faced the risk of being prosecuted by their state attorney general’s office. Similarly, in Minnesota, there is a statute making it illegal to pay for obesity medications (MN Statute 256B.0625, Subdivision 13D).

The turning point came in 1998. Faced with an epidemic of obesity that was clearly documented by the Centers for Disease Control and Prevention, the National Heart, Lung, and Blood Institute in collaboration with the North American Association for the Study of Obesity issued its Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity.4 These guidelines recognized obesity as a chronic disease. They also put science at odds with the administration within the federal government.

In 1999, the World Health Organization (WHO) published its consultation on obesity,5 highlighting the benefits of weight loss. Shortly thereafter, in 2001 Surgeon General David Satcher published theSurgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity.6 This document called to both prevent and treat overweight and obesity but failed to incorporate pharmacotherapy.

By the turn of this century, given pressure from the medical community backed by the growing evidence basis, a movement to recognize obesity as a treatable disease started to overcome bureaucratic hurdles.

Finally, the Internal Revenue Service issued a ruling on obesity making expenses for the treatment of obesity deductible medical expenses.7 This was a major leap forward in allowing patients with overweight and obesity to gain access to affordable medical care, legitimizing the condition for so many people.

In 2004, the Centers for Medicare and Medicaid Services (CMS) removed the phrase “obesity is not an illness” from its coverage rules, and this set the stage for coverage to be implemented at the federal level for obesity care.

Yet, the necessary next step has not been taken; obesity is still not a covered benefit under Medicare, with the exception of bariatric surgery.

Under the ABCD construct,3 healthcare professionals should continue to provide individual care to patients with overweight and obesity. If ABCD gains acceptance as a term, it may allow for the creation of billing codes that third party payers may then cover.

Beyond the individual patient encounter, each of us must educate patients and invite their advocacy with legislators at the local level and the federal government. Since about two-thirds of the country is affected by overweight and obesity, or ABCD, barriers to effective health care must come down, and this will require “a continued, concerted, and vigorous effort regarding health policy and the legislative agenda..” as posited in the AACE/ACE position paper.3

ABCD aims for a more clinically relevant term

AACE and ACE failed to adopt the term, adiposopathy, which was introduced by Dr. Harold Bays.2,8 Adiposopathy, clinically defined as sick fat, was the first term introduced into the medical literature as an alternative to the words overweight and obesity.

Adiposopathy, as a single word, is better than ABCD, especially in light of the many publications on the ABCDs of treatment for multiple medical problems that are in the literature already. The individuals behind the AACE/ACE decision to coin ABCD as the preferred alternative to overweight and obesity have the right concept, but in advancing ABCD, they pursued a personal agenda that is not universally endorsed by many of us in the field of bariatric endocrinology.

Adiposopathy is a much better term, like nephropathy, cardiomyopathy, ophthalmopathy, dermopathy, and neuropathy, adiposopathy, which succinctly encompasses the concept that adipose tissue actively contributes to the genesis of metabolic diseases when there are derangements of function or structure.

All things considered, the goals of AACE/ACE should be universally supported.

Patients with overweight, obesity, adiposopathy, or ABCD – regardless of the term used– have a disease that needs to be treated, and treated with respect. The practice of bariatric endocrinology, which is fast maturing, and the wider field of obesity medicine, shall overcome the bureaucratic obstacles that are still in place.

About the Author: J. Michael Gonzalez-Campoy, MD, PhD, FACE, is medical director and CEO of the Minnesota Center for Obesity, Metabolism, and Endocrinology in Eagan, Minnesota. a member of the AACE/ACE Obesity Review Committee, and is senior editor for the obesity section of EndocrineWeb. Dr. Gonzalez-Campoy earned his medical degree and PhD in physiology and biophysics from the Mayo Medical School and Mayo Graduate School in Rochester, Minnesota. He received a fellowship in diabetes, endocrinology, and metabolism from the University of Minnesota. His clinical and research interests include the prevention and treatment of obesity and adiposopathy, and their complications. He is past member of the American College of Endocrinology Board of Trustees and the American Association of Clinical Endocrinologists Board of Directors.

Mechanick JI, Hurley DL, Garvey WT. Adiposity-Based Chronic Disease as a New Diagnostic Term: American Association of Clinical Endocrinologists and the American College of Endocrinology Position Statement. Endocr Pract. 2016.

Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity: The Evidence Report. Washington, DC: National Heart, Lung and Blood Institute and The National Institute of Diabetes and Digestive and Kidney Diseases. 1998;NIH Publication No. 98-4083. Available at: https://www.nhlbi.nih.gov/files/docs/guidelines/ob_gdlns.pdf

U.S. Department of Health and Human Services. The Surgeon General’s call to action to prevent and decrease overweight and obesity. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; [2001]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK44206/

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